health

Site Visit to Guatemala – Dec 8-10, 2025

| alexandersanger

On Dec 8-10, 2025, I went to Antigua, Guatemala to visit two Fos Feminista partner organizations and to attend a Fos board meeting. Antigua is surrounded by 4 volcanoes, one of which was smoking. The nation’s capital was once in Antigua but multiple earthquakes in the 1700s led the Spanish authorities to move the capital.

Guatemala is the most populous country in Central America with over 18 million people. The country struggles with persistent inequality. The population is primarily Mestizo, but Indigenous Maya communities make up about 35 percent—the highest proportion in the region. Guatemala is home to 22 Mayan languages, which makes delivering health care challenging. Poverty is widespread. In 2023, 56 percent of Guatemalans lived in poverty, with 16 percent in extreme poverty. Rural communities and Indigenous peoples are disproportionately affected, with poverty rates exceeding 80 percent in some areas. Malnutrition among children is alarmingly high: 46.5 percent of children under five suffer chronic malnutrition, one of the highest rates globally. 

Guatemala faces a critical sexual and reproductive rights crisis. Adolescent pregnancy rates, particularly in rural and Indigenous communities, are among the highest in Latin America. Many of these pregnancies result from sexual violence, highlighting deep gaps in child protection and support systems. Early pregnancy often forces girls to leave school, limiting their opportunities and perpetuating cycles of poverty. 1 in 3 Indigenous women have no access to health and family planning services. 25% of teen girls are pregnant or parenting. The birthrate is 2.4. 

Challenges in the country have been further exacerbated by the recent US funding cuts to USAID and UNFPA which brought $605.5M in support for global family planning and reproductive health programming and services to an abrupt end. Guatemala was among the largest losers of funds. Birth control pills are currently out of stock in government clinics. 

The country has some of the most restrictive abortion laws in the world, permitting the procedure only when the life of the pregnant person is at risk. In practice, even these cases are difficult to access. Medical professionals often interpret the law narrowly, and social stigma further discourages care. As a result, many girls and women are forced to continue pregnancies, even in cases of rape or when their health is at risk. Illegal abortions proliferate. 

The two Fos partners there are: 

Founded in 1964, APROFAM (Asociación P r o B i e n e s t a r d e l a Fa m i l i a de Guatemala) is a long-standing partner of Fòs Feminista and one of the largest providers of sexual and reproductive health care in Guatemala and within the Fòs Feminista Alliance. In 2024, APROFAM provided more than 2.7M sexual and reproductive health services, including nearly 975,000 contraceptive services. APROFAM provides subsidized SRH services primarily through its clinics and occasionally through mobile clinics in collaboration with the Ministry of Health. It also offers general medical care including pediatrics.

And 

WINGS (Women’s International Network for Guatemala Solutions) has been a Fòs Feminista partner since 2019. Founded in 2001, WINGS provides quality, free or subsidized reproductive health education and services to low-income, rural, and Indigenous populations, reaching around 25,000 individuals annually. Their model is complementary to APROFAM in that WINGS focuses predominantly on rural, Indigenous, and underserved provinces in Guatemala that are not reached either by APROFAM or the public sector. In 2025, WINGS reached an important milestone in expanding their mobile health outreach to every department in the country.

On Day 1 we visited an APROFAM clinic visit 2 hours away from Antigua. It was a public health clinic that APROFAM was borrowing for the day. It was spotless. They provided good quality compassionate care. 

It was vasectomy day. I scrubbed up and observed one procedure. The patient was a man about age 35 or 40 with a few children (exact number undisclosed to me). Lively music was playing in the operating theater. A doctor, nurse and orderly did the procedure. It was very quick, 7 minutes, with lots of chatter with the patient who said he didn’t feel a thing. My high school Spanish being limited, I couldn’t understand what they were talking about – maybe football. All was very professional and relaxed. Patient was at ease and hopped off the table at the end. 10 more patients were done that morning. An 11th got a call from his office and left before his procedure. 

The clinic also does tubal ligations for women but not today.

Below — ACS in scrubs

ACS with clinic and Fos staff and volunteers. 

We next visited a health promoter’s house. She is part of the WINGS network. She is a nurse who does counseling and also inserts implants and IUDs in her home as well as providing injections and pills. Her 9-year-old daughter and family cat sat in, as well as an adult patient. There was also a teenaged male sex educator who spoke of his speaking to teens in schools. In the living room/consulting room was a chapel so that the patients can pray as they get care and feel absolved.

ACS with the WINGS nurse-educator.

These organizations are doing life saving work in very difficult circumstances.

Birth rates, Fertility and What To Do

| alexandersanger

The CDC reported last week that births increased by just 1 percent in 2024 with the fertility rate (TFR) remaining level at about 1.6, well below the 2.1 level needed to maintain the population level through births alone (i.e. without immigration). 

At the same time, the Guttmacher Institute estimated that clinician-provided abortions in 2024 in states without a total abortion ban increased also by slightly less than 1 percent from 2023. There were additional abortions of an undetermined number that were not clinician provided. 

The Trump Administration is considering ideas to increase the birth rate, among them a $5,000 baby bonus, tax credits for children, increasing the availability of IVF, and awarding medals to mothers of a certain number of children. Worldwide incentives of this sort have been largely money wasted. My October 16, 2024 post talks about Norway and Hungary’s futile efforts to increase their birthrates. At most, incentives have speeded up childbearing but not increased the number of desired children. Russia awards an Order of Parental Glory to parents of large families. It hasn’t stopped the decline in the Russian TFR. A similar award in France has had no effect either.

The Administration’s cutting of Title X funding for family planning and threatened cuts to Medicaid program (as well as criminalizing abortion if they seek a nationwide ban) will perhaps serve to increase unintended childbearing, especially among teens. The decrease in the national TFR has come because of a reduction in teen pregnancy over the years largely due to better and longer-lasting contraception. Teens and young adults are also reporting having less sex. Criminalizing abortion further and reducing access to contraception may serve as further deterrents to sex and hence pregnancy, but I suspect the pregnancy and childbearing rates will rise among those without access to private family planning services, i.e. the poor and minorities, exactly the groups that the conservative White Replacement Theory folks don’t want to reproduce. 

The issues around infertility and IVF are tying the Administration in knots given the sway of absolutist anti-abortion people in policy circles. The imperatives of couples wanting a child by any means often outweigh their beliefs on abortion. 

The causes of infertility in males and females are debated, but one thing is sure: sexually transmitted infections can cause infertility. And the Administration by cutting reproductive health care programs will be increasing STIs and hence infertility. 

Who ever said politics makes sense. 

The Forest obscuring the Trees

| alexandersanger

In the midst of the tariff forest, or conflagration to switch the metaphor, we cannot lose sight of the trees – Administration’s devastating attack on reproductive, and general, health of people here and abroad. And the attacks are just beginning.

The Administration has suspended Title X funding for family planning clinics in this country but also USAID grants for reproductive and other health around the world. Title X supports the provision of reproductive healthcare, including family planning and the treatment and prevention of sexually transmitted diseases in family planning clinics in this country. Many of those clinics are operated by Planned Parenthood. None of the funds can be used for abortion services. A total of $66 Million in Title X funding has been suspended, including $21M for Planned Parenthood clinics. These programs have been audited repeatedly to make sure that this does not happen, yet this administration under the guise of fiscal probity has suspended the funds to do yet another investigation. The effect of this suspension will be that clinics will be turning away low-income patients who will have nowhere else to go and will lead to increases in sexually transmitted infections, cervical cancer and pregnancy rates, and therefore abortion rates.

The next shoe to drop is probably Medicaid funding going to Planned Parenthood and other reproductive healthcare clinics. Medicaid funding reimburses clinics for reproductive healthcare visits, including family planning and sexually transmitted disease provision for clients who are eligible for Medicaid. If and when these cuts are enacted, and there are sure to be challenges because these funds are budgetary provisions, enacted by Congress, and it will lead to the closure of many family planning clinics nationwide. Patients will have nowhere else to go. On top of this, the Supreme Court this week heard arguments about whether or not states can prohibit Medicaid recipients from using clinics which also provide abortion services, i.e Planned Parenthoods. Planned Parenthood receives about one-third of its revenue from Medicaid and Title X.

Planned Parenthoods nationwide are facing huge budgetary pressures, as are many healthcare providers, with rising costs, especially salaries for nurses, doctors and other trained personnel. My old affiliate, Planned Parenthood of Greater New York (PPGNY), recently announced that they were putting up for sale the building that houses its Manhattan clinic and would be closing the clinic. They said they hoped to open in Manhattan clinic at another site, but there are no definite plans. The affiliate, along with many other Planned Parenthood affiliates nationwide, have been closing under-performing clinics because they cannot be subsidized in the current climate. PPGNY and PP Illinois have recently closed four clinics each. This has led to greater travel, and other costs, being imposed on rural patients, as well as delay and forgoing of health care.

Planned Parenthoods around the country that provide abortion services are inundated by patients from states where abortion has been criminalized. The resulting subsidy that patients need, including travel costs and accommodations, as well as the fees that they are unable to pay are devastating the finances of Planned Parenthood. This is a human and public health crisis, and states that keep abortion legal must do more to make abortion as safe and accessible as possible. Women are going to resort to do-it-yourself abortion and not under a doctor’s care which could lead to injury and death. Those doctors who are mailing abortion pills internationally and across state lines are not reaching every woman who needs an abortion. About half of women coming to Planned Parenthoods nationwide are using abortion pills, but many are opting for surgery because the procedure can be done in the same day and the woman can return home without delay or risk of needed a followup visit in a state where abortion is criminal.

There is a curious intersection, and disconnect I believe, with much of the conservative ideology about white supremacy. The attacks on Planned Parenthood will reduce reproductive healthcare as well as abortion services in areas with large white populations. If the conservatives hope as a result the white birth rates will go up, that might happen (preliminary data shows an increase in births in criminalized states – the abortion rate has also gone up!). But these attacks will also end up resulting in the closure of clinics serving minority populations, so those birth rates will also go up. In all cases, there will be an increase in sexually transmitted diseases (and illegal abortions), which in many cases cause infertility, thereby decreasing the nation’s ability to increase the birth rate. Talk about counterproductive.

The middle of all this chaos, families have to sort out whether and when to have children. One of the factors that men and women will take into account is how they view the future. Certainly the tariff chaos will give financial pause to many in every state and of every political persuasion. People are now poorer than they were a month ago, and one can question whether they see any light at the end of the Trump tunnel. Some conservatives are beginning to see that they should offer incentives for married couples to have children, though incentives offered in various countries around the world have done little or nothing to increase birth rates.

The intersection of the tariff policy with the anti-immigration policy gives political concern. Many areas of this country have seen population growth and economic vitality from immigration. If these areas are depopulated through deportations, the economies there will stagnate and decline. One US study called it, “Depopulation, Deaths, Diversity and Deprivation: the Four D’s of Rural Population Change.” This scenario played out in the former East Germany recently, an area where people of ability left for greater opportunity in the former West Germany, leaving behind people with fewer opportunities and social services, who were full of resentment, and therefore voted for far right political parties. This would naturally buoy the Trump party even though he was the cause of it all.

visit to dominican republic

| alexandersanger

Last week I spent five days in the Dominican Republic visiting the Fos Feminista partner Profamilia, which has 7 clinics and 2 mobile health units. 

The DR is poor. Baseball is the national sport. Each major league team has a baseball academy in the DR. Sugar cane employment is declining. Teen pregnancy is very high – about half of teens give birth. Girls do not see much of a future. 

The clinics were spotless, full of clients and well run. You could tell the dedication of the staff and their professionalism. Clients were treated with respect. 

Abortion is totally illegal in the DR, so it is not provided. The clinics do offer harm reduction, where they explain what to do in the event the client has an illegal abortion and has complications. The Profamilia clinics can and do manage any complications or tell the patients go to a hospital. They are working with the legislature to allow three exceptions to the ban on abortion – to save the life of the mother, fetal abnormality and rape. 

The clinics offer a full range of contraception and sterilization, male and female. The pill and injection are the most common methods. Some women have to disguise their pills as vitamins from their husbands. Many men in DR want many more children than the women want. Emergency contraception is becoming used as a method of contraception. It becomes less effective if used frequently.

Pills and other methods are sold without prescription in pharmacies. Profamilia does extensive community distribution of pills.

There is universal screening for domestic violence, which is common. The clinics offer legal services for victims. There is a shortage of safe houses – there are 12- and few relocation services. There is a national DV hotline.

Men constitute 20% of patients, mostly for urology. One clinic did 20 vasectomies a day.

The clinics do HIV counseling and treatment.

The clinics offer general health care and pediatrics but no deliveries.

The services are free if the client cannot pay. There is national health insurance.

Maternal mortality is high but declining. It is about 107 per 100,000 in 2020 and increased during Covid. Illegal abortion now constitutes 8% of maternal deaths – it was 20% during Covid.

We visited three mobile health unit sites in remote villages and batayas- these are Haitian immigrant villages where sugar cane workers and farmers live. Sugar cane has become largely mechanized and many Haitians are scratching out a living farming or manual labor. $6 a day is the average wage in the batayas. If a person needs to get to the nearest hospital it costs $12 for transport. The Hailtian migrants fear hospitals due to deportation threats.

The community promoters , or promotores as they are called, are villagers trained by Profamilia, who live and travel around the batayas bringing contraceptives and general health care. The mobile health units are on a circuit and come every 30 days or so. One promoter just got her law degree and another is running for the local legislature.